Find information on general abdominal pain diagnosis, including clinical documentation, medical coding (ICD-10 R10.4, R10.9), differential diagnosis, and healthcare guidelines. Learn about symptoms, causes, and treatment options for abdominal pain, covering acute abdomen, chronic abdominal pain, and localized pain. Explore resources for physicians, nurses, and other healthcare professionals regarding proper documentation and billing for abdominal pain. This resource helps with accurate clinical evaluation and coding for generalized abdominal pain.
Also known as
Abdominal and pelvic pain
Generalized or localized pain in the abdomen or pelvis.
Other generalized abdominal pain
Abdominal pain that is not localized.
Functional intestinal disorders
Disorders of intestinal function without structural abnormality, often with pain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the abdominal pain localized?
Yes
Where is the pain localized?
No
Is the pain generalized?
When to use each related code
Description |
---|
General Abdominal Pain |
Localized Abdominal Pain |
Functional Abdominal Pain |
Coding R10.4 (general abdominal pain) when documentation specifies location lacks specificity, risking underpayment and audit scrutiny. CDI can clarify.
R10.4 may be coded inappropriately when a more specific diagnosis is documented, leading to inaccurate severity and HCC coding.
Insufficient documentation to support R10.4 makes it vulnerable to denials. Clear documentation of exam findings is crucial for compliance.
Patient presents with chief complaint of generalized abdominal pain. Onset of pain reported as (gradual or sudden), duration (number) dayshoursweeks. Pain quality described as (sharp, dull, aching, cramping, burning, gnawing). Location of pain is diffuse and not localized to any specific quadrant. Pain severity is (mild, moderate, severe) on a scale of 0-10, currently rated at (number). Associated symptoms may include nausea, vomiting, diarrhea, constipation, bloating, flatulence, anorexia, fever, chills, weight loss, or fatigue. Patient denies any hematemesis, melena, hematochezia, or dysuria. Medical history significant for (list relevant medical conditions). Surgical history includes (list surgeries). Current medications include (list medications). Allergies include (list allergies). Family history notable for (list relevant family history). Social history includes (tobacco use, alcohol use, drug use). Physical examination reveals (abdomen soft or rigid, bowel sounds present or absent, tenderness to palpation, rebound tenderness, guarding, or distension). Vital signs stable with heart rate (number) bpm, blood pressure (number)/(number) mmHg, respiratory rate (number) breaths per minute, and temperature (number) degrees Fahrenheit. Differential diagnosis includes gastroenteritis, irritable bowel syndrome, constipation, intestinal obstruction, mesenteric ischemia, appendicitis, diverticulitis, cholecystitis, pancreatitis, urinary tract infection, pelvic inflammatory disease, or other intra-abdominal pathology. Ordered complete blood count, comprehensive metabolic panel, urinalysis, and abdominal imaging (X-ray, CT scan, ultrasound) to further evaluate. Patient advised on symptomatic management with pain medication, antiemetics, and hydration. Return precautions discussed. Follow-up scheduled.